Mapping new voices. Towards a Latin American perspective on Global Mental Health. (Conference Report)

(Originally published in Somatosphere)

This article describes the creation of a collaborative initiative started by PhD students interested in mental health issues in Latin America. It reports on its first workshop “Mapping new voices. Towards a Latin American perspective in Global Mental Health” held at the Maison de Sciences de l’Homme in Paris on the 26-27 of June 2017.

 

The call for scaling up mental health services in Low and Middle-income countries, initiated by Euro-American psychiatrists and institutions during the early 2000s, has received “mixed reviews”.  A significant amount of literature has emerged to interrogate the underlying motives and affinities of the Movement for Global Mental Health (Campbell & Burgess, 2012; Summerfield, 2012). Alongside important gains in mobilising attention and resources to scale up mental health services in the global south, the imposition of western modes of thinking and acting upon human suffering across cultures have been especially contested (Mills, 2014; Mills & Fernando, 2014).

Beyond these controversies – or probably because of them – the notion of global mental health has gained ground, becoming an irreversible descriptor of contemporary policy practices and aspirations and producing an on-going discussion that involves different voices and disciplines. In June 2016, one such conversation started. A small group of PhD students in the social sciences gathered to discuss and debate their projects on mental health in Latin America. Several things became clear: 1) although the Movement for Global Mental Health had become ubiquitous in academia, somehow Latin America did not seem to be part of its focus; 2) the social sciences have only had a minor role within this field of study; and 3) epistemological and political questions were hardly considered in the main calls for action and research (Lancet 2007, 2013).

Platform for Social Research on Mental Health in Latin America (PLASMA)

These questions laid the ground for further reflexion and networking. The group started to get in touch with different doctoral students and early career researchers working in the social sciences and sharing an interest in Latin America’s mental health issues and policies. Eventually a team of eight doctoral students from Latin America was formed. We come from diverse training backgrounds in anthropology, sociology, epidemiology and psychology and are based in different universities in London and Paris. We are currently conducting research in or about Chile, Brazil, Peru, Colombia and Argentina. The outcome of this process was the creation of the Platform for Social Research on Mental Health in Latin America (PLASMA).

An initial concern for us was the need to highlight the specificities and diversity of Latin America vis-à-vis the universalistic ambitions of global mental health, adopting a critical and comparative perspective of the region. That is, highlighting how political, cultural and social processes find expression in the mental health issues affecting the area, and in their description and intervention. Some questions emerged: How can the singularities of Latin America (i.e. particular modernisation processes, forms of inequality, social conflicts and political violence) be included in the study of the globalisation of psychiatry and mental health? Does “globalisation” influence the expert and lay descriptions and approaches to human suffering in Latin America? The persistent outcome of these deliberations was the recognition of the complexity of Latin America, and the desire to extend and enrich the conversation.

PLASMA wants to be a space for students and early career researchers to exchange ideas and collaborate. It aims to explore how the historical and socio-political characteristics of the region play a part in the way mental health problems are framed, acted upon and experienced. Based on this, the aim is to engage in a critical discussion about global mental health’s epistemic and political characteristics.

Workshop: “Mapping new voices. Towards a Latin American perspective in Global Mental Health”.

A call for papers was drafted, and several funding opportunities were approached. The call had a positive response, and 27 abstracts were received. Abstracts were evaluated by a scientific committee which included prominent scholars in the field. Ten papers were selected and distributed across four thematic sessions: 1) “Historical mental health issues in Latin American countries”; 2) Challenges for mental health policy in the region” 3) “From diagnosis to experience: Different voices, different approaches” 4) “Global tendencies, local realities: Global Mental Health and Latin American perspectives”.

The two-day workshop was titled “Mapping new voices: Towards a Latin American perspective in Global Mental Health”, and it was held at the Maison de Sciences de l’Homme in Paris. It included the presence and support of a group of scholars that had both participated and critically engaged with global mental health. Anne Lovell gave a talk on metrics in this field; Catherine Campbell on community mobilisation, agency and social change in the mental health field; and Clara Han on subjective and social experiences on death and violence in Chile. China Mills, Livia Velpry and Ursula Read gave commentaries and prompted the debate further. The workshop ended up with a collective discussion led by the PLASMA group called “Towards a Latin American perspective on Global Mental Health”.

 

Key questions and themes that emerged in the workshop

During the different sessions of the workshop and throughout the varied topics and cases discussed, PLASMA’s original key questions remained present: How do the particular epistemologies, knowledge, practices and experiences on mental health taking place in Latin America enter in dialogue with the debate about global mental health?

Anne Lovell provided a framework to understand the kinds of transformations leading to the emergence of the Movement for Global Mental Health. According to her presentation, a set of metrics such as the Global Burden of Disease (GBD) and the Disability-Adjusted Life Year (DALY) had laid conditions and rules for conceiving mental illness on a global scale. This framework provides local and regional actors of low and middle-income countries (LMIC) access to resources but introduces at once new forms of governance. Through a global mental health framework, dominant agents create the standards for “forensic profiles”, evaluating countries’ capacities to generate reliable numbers on mental health. She also showed how, in this process, “disability” became the standard measure of all diseases, bringing new visibility to mental disorder. This, however, mostly focusing on their negative effects on individual productivity rather than in others aspects of an individual’s life.

China Mills’ comments to Anne Lovell’s presentation focused on the impacts of the Movement for Global Mental Health on local policies and politics in LMIC, prompting the participants to contemplate the dangers of standardisation, objectification and neglect of local epistemologies and experiences.

The presentations in both days of the workshop addressed to a greater or lesser extent these kinds of concerns, and the potential impacts of the global mental health agenda in the Latin American region. These papers presented cases from Brazil, Chile, Colombia, Cuba, and Ecuador, which all highlighted the value of local experiences and epistemologies on mental health, according to their different historical, political, cultural and economic backgrounds.

Although Latin America is not a homogenous region, the presentations revealed the existence of common elements at the level of policy and practice. These differences and similarities are vital for recognising the region’s complexity and its particular input in the international debates on global psychiatry and mental health.

In the following section, these contrasts and commonalities are summarised in four transversal themes: (1) psychiatric epistemologies and public policies on mental health; (2) socioeconomic dimensions and mental health; (3) subjectivities and local experiences on mental illness; and (4) agency and community mobilisation.

 

  1. Latin American psychiatric epistemologies and public policies on mental health

Maria Castro and Steve Melluish’s presentation showed to what extent the societal function and ethical scope of psychology and mental health policies in Cuba differed from other countries in the region. Papers by Sebastian Fonseca, Marcelo Valenzuela, Nicolas Morales, Karla Ramirez and Khalil Rujana, on the other hand, demonstrated the existence of similar mental health policy processes across the region, rooted in epistemological tendencies coming from Europe and elsewhere.

All these presentations highlighted the need to reclaim the value of local intellectual traditions in mental health, including social medicine and politically oriented psychoanalysis; as well as the social science disciplines’ and mental health professionals’ historical commitment to the vulnerable, the poor and the victims of violence.

  1. Socioeconomic contexts and mental health

Many of the papers emphasised how policy and practice were intertwined with social, economic, political and cultural contexts. These contexts are crucial to understanding how policies work (or fail to do so), and how specific groups experience “illness”. But beyond this sheer diversity, the presentations and discussions allowed for the identification of a series of common factors and challenges such as the political, cultural and economic aftermath of dictatorships; political and structural violence; issues of urbanisation, inequality and segregation; and the marginalization of indigenous knowledges and practices regarding mental well-being and suffering.

Manuel Capella and Sushrut Jadhav’s presentation illustrated how the presence of mental health issues challenges mental health policies in Ecuador amidst a context where structural and cultural violence looms, and where many multiple notions of “wellbeing” coexist. Likewise, Karla Ramirez and Khalil Rujana highlighted the intricate relationship between political violence, mental health and problems of policy implementation in Colombia. Overall, there was consensus to comparatively assess the impact of those processes upon policies through social research.

  1. Subjectivities and local experiences on mental illness

A third transversal theme concerned subjectivities and local experiences of mental illness. Clara Han, in her keynote presentation, carefully analysed how mourning, distress and care are expressed in the ordinary lives of people living in contexts of structural violence, poverty, and inequality. Drawing on her current ethnographic work with families in a low-income neighbourhood under police occupation in Santiago of Chile, she detailed the ways that children come to learn kinship in a setting of pervasive death. She described how the process of re-making their world and kinship is woven by a complex interplay of death and life, absence and presence.

Livia Velpry made an insightful comment on the originality of Clara Han’s anthropological work as she approaches mental health from the texture of ordinary life, rather than framing it through a care institution. According to Velpry, Han highlights how loss and care are woven into family relationships and everyday tensions, while at the same time, revealing the moral dilemmas of the Chilean neoliberal society.

Other papers were also focused on the encounters of experts’ practices and knowledge with survivors of political violence (Gina Donoso), refugees (Gesa Duden), and of people diagnosed with mental illnesses (Alejandro Castro). These presentations demonstrated growing attention towards how mental health embodies critical moral dilemmas, how subjects act and think in particular ways in different places, and how psychiatric knowledge, practices and performativity enable the formation of new subjectivities.

  1. Agency and community mobilisation

In her keynote presentation, Catherine Campbell drew on her extensive work on community mobilisation on health and mental health. She focused on how researchers and professionals can work alongside affected communities to create health-enabling contexts, considering available examples of both success and failure. Community mobilisation and processes of collective empowerment are a recognisable feature of Latin America’s intellectual and practical approaches to social problems. For this reason, her words, and the comments given by Ursula Read, profoundly resonated with the audience.

The discussion expressed a keen awareness of the need to inform mental health practices with participatory and democratic principles. This was illustrated in some papers by the positive outcomes of users’ struggles against institutional powers, in a context of a predominantly top-down policy implementation. At the same time it was pointed out that the existence of participatory mechanisms doesn’t prevent the emergence of standardized procedures ensuing from the negotiations between patients’ associations, insurances, pharmaceutical companies, medical institutions, and other relevant actors.

In the last roundtable, in which all participants were invited to speak up and provide ideas for PLASMA’s next steps, the need for participatory spaces that include the perspective of service users and indigenous people was highlighted. To acknowledge these aspects means to problematize how and when different kinds of evidence are produced, for whom and for what purposes.

 

Conclusions

This meeting established a common working route and some challenges around the role of the social sciences in the mental health field. The presentations and conversations shared a concern about the problematic simplification of subjective problems operated by international standardised frameworks. In light of this, the social sciences can restore the complexity of individual suffering while at the same time, providing a better understanding on how local epistemologies and political commitments are intimately connected with mental health conceptualisations and practices.

However, it is also relevant to recognize that the globalisation of mental health discourses and interventions provides an opportunity to enable a different relationship between global and the local scales. Such relationships could allow regions that are usually taken as recipients of knowledge and interventions to re-emerge as sources of knowledge, conceptualisations and interventions around human suffering and social adversity.

The challenge is to create a body of research that translates the abovementioned tensions in their theoretical, methodological and empirical aspects. If done correctly, Latin America could become a crucial region for studying the globalisation of psychiatry and mental health and the role of local systems of values and collective representations shaping mental health and ordinary life. This first workshop was a small step in that direction.

As for the broader challenges ahead, PLASMA’s goal is to become a collaborative and synergic space from which researchers and institutions from diverse countries can expand the possibilities of social scientific research into mental health issues in the region.

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